Jan 12 "All great truths begin as blasphemies:" The Ignaz Semmelweis story

I wouldn't call myself a full-fledged germaphobe, but I probably demonstrate a little too much zeal in trying to stay clean. For instance, I both flush toilets and open bathroom doors with my feet;sometimes I feel inclined to shower after I get home from a public place, like a mall. Suffice to say, I get grossed out easily. Something that comforts me though is that we, in the West primarily, live in the cleanest period of all time, or at least it genuinely seems that way. We wash our hands after we go to the bathroom. We shower so we don't constantly smell terrible. We drive cars, and they, unlike horses, don't leave literal trails of shit in the street. We have indoor plumbing, so we don't have to relieve ourselves in chamber pots that we keep under our beds. This all makes living today a much more pleasant experience than it was a few generations ago. The reason for our current level of cleanliness is not merely aesthetic; it is practical and very necessary. When we are constantly being exposed to gross stuff like garbage, excrement, or germs, we tend to get sick and die. Now, this seems painfully obvious in 2017, but a definitive link to gross stuff and disease did not get proven until the 1860's with the discovery of the germ theory of disease. Germ theory proved that diseases are caused by very very small microorganisms. Before that, people went around licking signposts, coughing all over each other and then just blamed it on the jews when they got sick.

The most prominent theory about what caused sickness for a really long time was the “Miasma theory.” Miasma is greek for “pollution” and it was widely believed that diseases were simply caused by “toxic air.” For instance, the theory held that being exposed to feces didn't get you sick from bacteria, (remember this was not discovered yet) but because of the toxic air that emanated from it. They were not completely off, being exposed to feces did get you sick, they were just wrong about the cause. One interesting application of this idea can be seen by looking into the origins of the word “Malaria.” Malaria comes from the medieval Italian words Mala Aria, which literally mean “bad air.”It was named this because people tended to become ill when they hung out around marshes at night and this was attributed to the air exuding from the swamps. You really think someone would have noticed the other correlation, people getting sick after being bitten by mosquitos (which are more active in the evening) while hanging around swamps at night, but it took a while for anyone to put that together.

A picture from the 1830's illustrating “bad air” causing the cholera epidemic. As you can see, they seemed to think that the disease generated spontaneously from the air.

Our lack of understanding of etiology (what causes disease) and epidemiology (how disease spreads) had some very dark consequences in that it caused people to die at rates that were absolutely absurd; and as evidenced by people buying into the miasma theory, we had no real clue as to why they were dying. A great example of this was “The Black Plague,” which began in 1346 and killed an estimated 70-200 million people in just seven years, including up to 60% of Europe. The disease was caused by the microbacterium Yersinia Pestis, which was transmitted by a type of flea that came over to Europe via rats on trade ships. When someone was bitten by the flea, they became deathly ill and highly contagious. Since streets in this time period tended to be filled with garbage, feces, and rats, these fleas were everywhere and a lot of people became infected.

“Oriental rat flea (Xenopsylla cheopis) infected with the Yersinia pestisbacterium which appears as a dark mass in the gut. when the flea attempts to feed on an uninfected hostY. pestis is regurgitated into the wound, causing infection.”

This seems pretty simple today, but try to answer the following multiple choice question about the contemporary causes attributed to the plague:

What did people in 1346 thing was causing the plague?

A.) This giant flee that just bit me.

B.) The Jews poisoning the wells. J

C.),,,conjunction of three planets in that caused a "great pestilence in the air" (Miasma theory.)

D.) Earthquakes

E.) Gypsies

F.) All the above besides A.

The correct answer is F.

So as you can see, our ability to diagnose, treat, and contain the spread of disease in the current day and age should not be taken for granted; it is not an ability that we have always had.

One very popular way to die for much of history was during childbirth. Woman often contracted “Puerperal Fever” during labour, and it was often deadly. Puerperal fever, formally known as “Childbed Fever,” is a general name for several types of postpartum infections caused by bacteria in a woman's vulnerable genital tract between one and ten days after childbirth. Deaths caused by it today are very rare, but in earlier centuries they occurred at an alarming rate. In 17th century Europe and America, between 20 and 25% of woman succumbed to puerperal fever and in some epidemics, there was actually a 100% mortality rate, meaning that if you were giving birth in a particular clinic at a particular time, you, without a doubt, would die. In one Vienna hospital, the mortality rate was so high that women would jump out of ambulances and give birth on the street once it struck them that making it to that particular hospital was pretty much to a death sentence. One prominent physician at the time wrote that he would rather his children be delivered in a barn than a hospital and he was probably right, they would have been better off.

Disturbed by the alarming maternal death rate, one Hungarian physician from the early 1800's, Ignaz Semmelweis, came up with a solution to the epidemic of maternal death. His grand idea was, wait for it... that doctors should disinfect their hands before delivering babies. When used, his methods were able to send the disease rates at his hospital down from as high as 31% in one month to as low as zero in other months. Because of the efficacy of his methods, he later became known as “the savior of mothers.” Instead of receiving copious praise and an award or two for his discovery, he was basically laughed at and ostracized because the greater medical community refused to believe his methods actually worked. See, Semmelweis had the unfortunate circumstance of being ahead of his time. He made his discovery decades before germ theory was confirmed, so it greatly conflicted with the leading theory at the time: washing one’s hands properly was dumb. As time went on, he became so frustrated with the medical community that he essentially lost his mind. He was admitted to a mental asylum where he died after just two weeks.

Semmelweis was an obstetrician and he didn't really buy into the whole miasma thing. His skepticism was largely driven by the disparate mortality rates from puerperal fever in two separate clinics he worked at. One clinic had an average mortality rate of over 11% but the other was only 2% and this distinction baffled him. After all, the clinics were virtually identical besides one detail:; they were open on alternate days and therefore had different staff. Clinic one was staffed by medical students but the other was staffed by midwives. Which clinic do you think displayed the higher mortality rate? Incredibly, the clinic staffed by medical students. The reason for this was because the midwives only had one job:, to deliver babies. The students however, had a second role; they were constantly performing autopsies. So when the student was helping to deliver a baby, they had dead person all over them and got it all up inside the laboring woman. For a long time, Semmelweis was absolutely baffled and distressed by the high maternal death rate.

It took Semmelweis some time to figure out what was going on, but he finally realized the causes of the disease after his colleague was stabbed by a scalpel while performing an autopsy and subsequently died. At this point, a lightbulb went off in his head and he was like “Damn, this is incredibly obvious, people should really be washing their hands better. How have we been missing this this entire time, I need to go tell everyone.” He came up with a method that seemed to do the trick, washing ones hands in a chlorinated lime solution before each delivery, and did his best to spread the word.

Though Semmelweis's methods worked wonders, almost entirely eliminating cases of Puerperal fever in some months, the greater medical community was very skeptical about his practices and refused to adopt them. There were a few primary reasons for this. Initially, Semmelweis insisted on an iatrogenic cause of Childbed Fever, meaning he attributed the infection to a singular mode of infection. Semmelweis believed that the sickness was strictly caused by “cadaveric particles” transmitted to patients from doctors who performed autopsies, and he refused to acknowledge any other possibilities. Semmelweis made sure everyone knew this and he was far from gentle with his accusations, constantly insulting his fellow doctors and even calling them “murderers.” Semmelweis's contemporaries grew tired of his constant finger pointing and it led to an indelible rift between him and the rest of the Vienna medical community.When evidence began to show that Semmelweis was wrong, childbed fever could be caused by numerous means, he started amending his theory with some scientifically questionable assertions. For instance, when several women in one room died despite doctors engaging in hand disinfection, Semmelweis blamed the deaths on another patient with a wounded knee. He asserted that the discharge from the knee traveled through the air and into the other women's uteruses, thus causing a deadly infection. Semmelweis also had to overcome the hurdle that was his inability to completely eliminate cases of childbed fever. Even when his methods were strictly enforced, some women still regularly died under his care. To cover for this discrepancy, Semmelweis announced that a second type of cadaveric particle could cause the infection, a particle native to the patient herself. When tissue died in the birthing process, Semmelweis held, it had the capability to infect the women, independent of foreign particles.

Ironically, Semmelweis's findings were viewed as unscientific, and in a way, they actually were. Despite his own observations, Semmelweis was no other evidence to support his claim, and his studies were very poorly conducted. Most damning of all though, again, was that this all took place years before we knew that disease causing microorganisms even existed. Because of this, Semmelweis was essentially asking that his contemporaries take his “cadaveric particle” method of transmission on faith, something that they were loath to do. Because doctors did often wash their hands before delivering babies, albeit poorly, they were incapable of grasping that something on their hands, not visible to the naked eye, could be causing fatalities. One doctor was quoted saying the following:

“...a rapidly fatal putrid infection, even if the putrid matter is introduced directly into the blood, requires more than homeopathic doses of the poison. And, with due respect for the cleanliness of the Viennese students, it seems improbable that enough infective matter or vapor could be secluded around the fingernails to kill a patient.”

“Microbial growth on a blood agar plate without any procedure (sector A), after washing hands (sector B), and after disinfecting hands with alcohol (sector C).”

You can see that washing hands with just soap and water barely does anything to prevent disease being spread from doctor to patient, while full disinfection does a very good job.

Over time it became clear to Semmelweis that he was no longer wanted at his hospital so he decided to try his hand at teaching. He was offered a position but with the caveat that he not be allowed to work with any cadavers. He would have to exclusively teach with leather mannequins instead, because screw him. Next, he left Vienna and took a position at a hospital in Budapest. There, he instituted his methods of rigorous hand washing and, once again, all but eliminated the instances of the fever. Incredibly though, the wider medical community still refused to implement his practices.

All of this understandably made him very upset, and he began to go off his rocker. He sent letters to many of his colleagues and called them “Irresponsible murderers” and “Ignoramuses.” He began to drink heavily and see prostitutes. The only thing that could console him was that his practice might one day be widely accepted.

"When I look back upon the past, I can only dispel the sadness which falls upon me by gazing into that happy future when the infection will be banished . . . The conviction that such a time must inevitably sooner or later arrive will cheer my dying hour."

As time drew on, Semmelweis began to lose it so much that his friends and family became legitimately worried about him and they eventually sent him to an insane asylum in Vienna. In the process of attempting to commit him, Semmelweis's friend pretended that they were going out for ice cream*. When they arrived though, Semmelweis realized that this particular Baskin Robbins looked very much like an insane asylum and the workers looked very much like orderlies, so he attempted to leave. He insisted that he was not crazy, but the orderlies thought otherwise. They beat the crap out him, put him in a straight jacket, and tossed him in a cell. In the asylum, he was treated by being administered laxatives and being doused with freezing cold water as if he was going to shiver and shit his mental illness out. His cause of death was pyemia, a severe blood infection. The infection was likely caused by his being beaten by guards who neglected to properly wash their hands.

*this part is a joke

Standard practice at the time for the “Hungarian Association of Physicians and Natural Scientists,” which Semmelweis was a part of, was for there to be a presence and a commencement at the funeral of each member. For Semmelweis though, they neglected to enforce this practice. There was no acknowledgment of his death, no commencement took place, and very few people showed up at his funeral.